- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.73 / $677.57 / $881.83
| Professional | | $506.73 | $677.57 | $881.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $698.61 / $998.02 / $1,330.23
| Professional | | $698.61 | $998.02 | $1,330.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.90 / $1,361.16 / $1,941.23
| Professional | | $540.90 | $1,361.16 | $1,941.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,654.00 / $3,447.00 / $7,350.00
| Facility | | $2,654.00 | $3,447.00 | $7,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.10 / $1,187.11 / $1,775.79
| Professional | | $734.10 | $1,187.11 | $1,775.79 |